ICD-10 Coding for Abnormal Computed Tomography(R93.89, R93.2)
Complete ICD-10-CM coding and documentation guide for Abnormal Computed Tomography. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Computed Tomography
R90-R94Primary Range
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
This range includes codes for abnormal findings on imaging studies when no specific diagnosis is confirmed.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R93.89 | Abnormal findings on diagnostic imaging of other specified body structures | Use when imaging shows abnormal findings without a confirmed diagnosis. |
|
| R93.2 | Abnormal findings on diagnostic imaging of liver and biliary tract | Use when imaging shows abnormalities specific to the liver or biliary tract. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal CT scan
Essential facts and insights about Abnormal Computed Tomography
Primary ICD-10-CM Codes for abnormal computed tomography
Decision Criteria
clinical Criteria
- Impression section indicates abnormal findings without a specific diagnosis.
documentation Criteria
- Radiology report lacks sufficient detail to confirm a specific diagnosis.
Applicable To
- Non-specific findings such as masses or opacities without confirmed diagnosis
Excludes
- Confirmed diagnoses that explain the abnormal findings
Clinical Validation Requirements
- Radiology report impression section detailing abnormal findings
- Recommendation for follow-up or further investigation
Code-Specific Risks
- Incorrectly coding a confirmed diagnosis instead of using R93.89
Coding Notes
- Ensure documentation in the impression section supports the use of R93.89.
R93.2 - Abnormal findings on diagnostic imaging of liver and biliary tract
Use when imaging shows abnormalities specific to the liver or biliary tract.
Applicable To
- Liver lesions, cysts, duct dilation
Excludes
- Confirmed liver diseases such as cirrhosis or hepatitis
Clinical Validation Requirements
- Imaging showing specific liver or biliary tract abnormalities
- Correlation with clinical symptoms or lab findings
Coding Notes
Ensure imaging findings are specific to liver or biliary tract.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Computed Tomography to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R93.89.
Impact
Clinical: Leads to inappropriate follow-up actions., Regulatory: May result in audit issues., Financial: Can cause claim denials or reduced reimbursement.
Mitigation Strategy
Train radiologists on detailed documentation., Implement standardized reporting templates.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of patient records.
Mitigation Strategy
Use R93.x codes until a diagnosis is confirmed by clinical correlation or biopsy.
Impact
Using unspecified codes when more specific codes are available.
Mitigation Strategy
Ensure documentation supports the most specific code possible.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Computed Tomography, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Computed Tomography
Use these documentation templates to ensure complete and accurate documentation for Abnormal Computed Tomography. These templates include all required elements for proper coding and billing.
Abnormal CT findings in the liver
Specialty: RadiologyRequired Elements
- Indications
- Findings
- Impression
- Recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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